Field notes: One small action changes a patient's experience.

Getty Images/Christian Adams.

When ERs are crowded, providing the best care is challenging. First, there’s the issue of safety. Then, there’s the issue of being present for my patients.

ER crowding is a huge problem, and not one I can solve. Still, I want to share a “hack” that I’ve used to make things just a bit better for my patients when things are exceedingly busy and I want to make sure they feel well taken care of…

First, a wind-up.

ER crowding is a huge issue.

Why are ERs suddenly more crowded? Well, it’s not a sudden change. It’s been a growing problem for years. The basic mechanics are easy to grasp:

1. Demand for emergency care has increased over the decades.

2. Inpatient hospital wards are more frequently at capacity.

The result? Emergency room real estate is getting scarce. We frequently have more patients than we have room for. When patients admitted to the hospital don’t actually have a bed or room upstairs, they have to wait in the ER. This is called “boarding.” Yes, patients can technically get most (and often all) of the care they need regardless of their location, but there are many problems with boarding, safety being the main concern.

And yet, ERs cannot turn anyone away, due to a law called EMTALA. Nor would we want to! As I often say, EMTALA is both our mandate and our mission. We are there to help all comers at all times.

So what happens when all the rooms in the ER are full? Patients are put in stretchers, lining the hallway. It is such a frequent problem that “hallway care” has its own research.

Things in Boston have gotten worse over time, but it’s still nothing like I used to see in New York, where stretchers were lined up in rows that eventually looked like a beach on the French Riviera (minus the beauty).

Getty Images/Alexander Spatari.

That said, hallway patients can be a challenge. First, there’s no conversational privacy. So, we have to speak quietly. (Doesn’t work for those who are hard of hearing.) Second, there’s no physical privacy. So, the physical exams we can do are limited. We often have to wait until a room opens up so we can temporarily move a patient to do any physical exam that may compromise modesty.

The best listening tool has nothing to do with hearing.

But even if we do everything right for hallway patients, there’s the issue of whether patients feel seen and heard. Look, hallway care makes me uncomfortable too. So, I often catch myself subconsciously looking for ways to hurry the process up. That’s bad. It can backfire. Rushing does not work, in the long run. As I learned in residency, oftentimes “slow is fast, and fast is slow.”

Recently, I had an otherwise healthy young patient who had some concerning symptoms that had appeared and then resolved spontaneously. The options for testing were pretty wide, ranging from very little to “the million dollar work-up.” After some careful thought (and minimal testing), I began to suspect that doing more would be bad. We weren’t going to figure out what happened—and that was probably okay. It would be a waste of time and the most likely thing was that we’d find no satisfying answers, other than red herrings. I did not want to “enroll” the patient in a long windy road to wrong answers. In some cases, “medical misadventures” can actually cause harm.

My plan was to explain all of this to the patient. But often, patients feel like the less we do, the less we care. That’s simply not true, though I understand the origin of that emotion. I sensed that doing this in the hallway was going to be a problem. It was going to look like I was shrugging off these concerns, even though I was not. I did not want that to be the impression.

So, I walked over to the patient and said, “Hey, let’s talk about the next steps.” Then I paused and said, “This actually warrants a real conversation and I don’t want to rush it. I need something. I’ll be right back.”

The thing I needed was a chair.

Photo by Daniel McCullough on Unsplash

I fetched a chair and brought it over. I put it next to the patient, and I sat down. This created a little bit of a feng shui foul, because I was now partly blocking a thoroughfare where patients were occasionally rolling through. It meant standing up and picking up the chair a couple of times during what was probably a 5 or 10 minute conversation.

By sitting down, I could make eye-level eye contact. I was physically showing that I was not hurrying the patient out. I was showing them that this conversation was important—important enough to create a couple of brief inconveniences for the traffic pattern of that part of the ER. I was trying to telegraph that I was being thoughtful, not dismissive.

We went through my thinking and rationale for stopping the investigation. I answered a few questions. The patient went home without a barrage of unnecessary tests. No wild goose chases.

While I had a theory or two, I’ll never know for sure what had happened to the patient earlier that day. But I know that whatever it was, it was not a threat to them. I think that the act of grabbing that chair was the difference between a patient who felt attended to instead of an afterthought; the difference between a complaint and a letter of thanks.

Making the connection is simple, but challenging.

There have been times when I’ve felt a little burned out at work, I’ll admit. A couple years back, one of my mentors here suggested that I’d feel more fulfilled if I spent a little more time just chatting with my patients. The advice: sit down more often in the patients’ rooms. Shoot the breeze. Get to know them a little more.

Just the simple act of my sitting down conveys so much information to patients. It says, “I’m here, I’m yours, I’m listening.” In exchange, patients really do tell me more information, some of which is often useful, some not, but all of it helpful in establishing a doctor-patient relationship quickly.

When I take the time to sit down, patients trust me sooner. Taking that time up front means that, later, when I’ve made my medical decisions, they’ll more likely feel confident that I care about them. Sometimes it means they’re willing to accept going home without answers—because I’ve convinced them that it’s going to be okay.

Slow is fast.

You all know I’m a big fan of technology. Sometimes, though, the simplest things make the biggest difference. For ER doctors who spend a lot of time running around, often the thing we need most is just a chair.

I’m always interested in hearing your stories about doctor-patient interactions. Please share your thoughts!